The facet orientation was determined by A-P X-ray films of 20 dried specimens of lumbar spine, and the facet angle and spinal canal configuration were directly measured useing the same specimens. Difference between the sagittal and coronal plane facet on X-ray film was clearly identified in direct measurement of facet angle of dried vertebra. The critical angle was 50 degree. But there was almost no difference of facet angle between the oblique and sagittal plane facet. The sagittal facet plays an important role to spinal canal configuration in the lower lumbar spine. But determination of spinal canal configuration only by facet orientation useing X-ray film may lead us to misunderstanding. So our method of measurement, previously reported, is reasonable to determine the spinal canal configuration.
Correlation of the water-soluble contrast myelogram with operative findings in lumbar disc lesions were carried out prospectively in 109 cases (130 discs) from April 1973 to August 1978. We classified myelograms into five types in each views and operative findings of the discs into four types: normal, bulging, protrusion, and prolaps. The number of false positive myelogram was 10 discs (7.7%) and false negative myelogram was 3 discs (2.3%). From the above it is no doubt that this method is more effective and accurate than the method with oil-based contrast medium. We believe that A-P view reveals directions and size of herniation, oblique views reveal relation between root and disc and lateral functional views reveal grade of bulglng (degeneration) of discs.
Cystometry of 15 cases in cervical myelopathy was examined. Mild loss of controll and stress incontinence were complained of only 3 cases but cystometric results were obtained of the unhibited neurogenic bladder in a case and the hypotonic bladder in 5 cases. It was suggested that the incidence of cervical myelopathy with urinary disturbance contained of subclinical bladder dysfunction was relatively higher. These 6 patients who revealed bladder dysfunction were more severe than other cases with normal bladder function in neurological impairment but they got improvement postopeaiively of both neurological deficit and bladder dysfunction. We presume that the presence of urinary disturbance in cervical myelopathy might not be the factor influencing to postoperative results.
Disc herniation of cervical region is rare, because quantity of cervical disc is little, posterior longitudinal ligament is wide and thick, nucleus of cervical disc locates rather anterior portion than nucleus of lumbar nucleus, and there are uncinate process and postevior osseus dike. Recently we reviewed three cases with cervical disc herniation, then we obtain different features from common ceruical spondylosis. 1. Patients have suffered some trauma some months before. 2. Comparatively, symptom progress rapidly. 3. Degree of symptom has no relation with wideth of spinal canal. 4. Patient fall into myelopathy at an early stage. 5. Operation is effective. We emphasize that subtotal vertebrectomy and anteior spinal fusion is most effective.
Cervical myelopathy mainly due to developmental stenosis of the cervical spinal canal without apparent spondylotic changes is now accepted as a clinical entity. Twenty-four patients with this disorder have been treated surgically in our clinic since 1957. There were 15 males and 9 females, complained preoperatively of dominant motor disturbance such as clumsiness of minute finger movements or gait disturbance, but less radicular pain. The extent of the narrow canal is 4 to 5 vertebra. Myelogram in A-P view showed characteristically a central filling defect of the contrast medium with broad lateral gutter, presuming swelling or flattenning of the cord at the level of the block. Methods of operation taken for the patients were subtotal resection of the vertebral bodies or osteoplastic enlargement of the canal. Good results were obtained.
Thoracic myelopathy is not the disorder which is frequently encountered in the clinic. Recently, we experienced three interesting cases of this disorder. Gait disturbance and numbness of the lower limbs are the main symptoms in three cases. Case 1: 67 year-old male had thoracic myelopathy caused by anterior slipping of C7 (degenerative spondylolisthesis) with spondylosic changes in C5-T1. Excellent result was obtained by laminectomy. Case 2: 24 year-old female had severe thoracic myelopathy with large osteophytes at T3-4 thoracic spondylosis presumably based on thoracic scoliosis. Case 3: 52 year-old male had symptoms and signs quite likely to extra-dural hematoma at T7. However, surgical exposure revealed no hematoma. After the operation symptoms were improved.
Extirpation of the intervertebral disc was carried out in 423 cases with disc disorders during the past 15 years in our clinic. In 3 cases out of the (0.71%), postoperative discitis took place. The symptoms appeared with pain, dull sensation of the lumbal and glutaeal parts, 2 or 3 weeks after operation, which were different from those at the preoperative stage. There observed a rise of BSR, positivity of CRP and slight fever without leucocytosis. The roentgenographic changes occurred about 1 month after surgery, showing the narrowing and irregularity of the disc space. The patients showed improvement by administration of antiboitics and bed rest for about 12 weeks. In one case, resaucerization of the intervertebral disc and anterior body fusion was performed and Gram negative bacillus was detected.
During recent years tuberculous spondylitis has become relatively uncommon, whereas osteomyelitis of septic origin has increased in frequency. The symptomatology of pyogenic osteomyelitis of the spine has been described by several earlier authors. It is difficult to differetiate from other diseases, especially tuberculous spondylitis. The diagnosis is often delayed or missed completely. Therefore, bacteriological and pathological investigations by the trephine biopsy to the spine, are most impotant on the diagnosis and therapy for infectious disease of the spine.
An autopsy case of 19-year-old female is reported. She was affected with spinal cord tumor with major involvement of the upper thoracic segments. Initial onset was solely manifested by scoliosis and the scoliosis had been treated with Milwaukee brace for five years. Within next two years she gradually lapsed into apparent paraplegia and then died of pneumonia. Massive growth of anaplastic ganglioglioma in the upper thoracic segments (T1-T) was disclosed by pathological-anatomical examination.
Two cases of rare spinal tumors recently experienced were both misdiagnosed as a lumbar disc herniation. Disc protrusions were not found at operation. Case 1; A 20-year-old man was admitted to our clinic, whose chief complaint was lumbosciatica with intermittent claudication. A myelogram showed a narrowing below the level of the L4-5 space. The cause of that was an extradural lipoma. Case 2; A 33-year-old woman complained of coccygalgia and both sciatica. A myelogram showed a complete block at the level of the L2 body. A laminectomy was done from L1 to L5 and then the removal of almost all the intradural tumor was able to be performed under the operation microscope. The pathological diagnosis was ependymoma.
In this paper were presented our experiences in the surgical treatment of the total nine patients with cevical spinal cord tumor. They were consisted of one case of extradural tumor, six cases of intrdural-extra medural tumor and two cases of intramedural tumor. Hour glass tumor was found in two cases, who were operated on two times for difficulties in the total removal of the tumor mass. Good results were postoperatively obtained except for one case with intramedural tumor. Respiratory management should be sufficiently carried out to the case of tumor at the upper cervical levels.
In 1978, the mass screening examination of scoliosis was carried out for 10041 school children in Kumamoto City. The children aged 10 to 15 years were examined by their parents firstly and then by the orthopaedist. 579 children with malposture were found by the parents. 443 out of 579 were examined by the orthopaedist and 389 scoliosis were suspectedly found. X-rays were taken on 225 of them. The incidence for scoliosis was 2.17%. 181 children (1.81%) had structural scoliosis. All of them were idiopathic origin. The incidence for scoliosis with curves more than 10 degrees by Cobb method revealed to be 1.0%. The sex ratio was three males to five females in structural scoliosis. The majority of the patient with scoliosis showed the main thoracic curve type.
The purpose of this paper is to evaluate the results of gymnastic therapy for scolio sis. Materials: Eighty-eight cases (twenty-six males and sixty-two females ranging from three to seventy years of age) were studied. Duration of the treatment is ranged from three months to four years. Results: 1) Healing and improvement 33% No change 56% Aggravation 11% 2) This treatment was more effective for females, for the subjects less than eleven years of age and for the patients having the curvature less than 19°. 3) The good results were obtained in the left thoracic and thoraco-lumbar type of scoliosis.
Thirty-nine patients with idiopathic scoliosis were treated with our new underarm brace and their preliminary results were analyzed. The principle of our brace is based on the three-point pressure system; that is pelvic girdle, lumbar or thoracic pad, and thoracic frame (ring). Thoracic frame has also the function of the neck ring in the Milwaukee Brace. There were thirty-eight female and one male, and their average initial curve was 28.1 degrees and their initial age was 12.9 years old. The best results were obtained in patients with thoracolumbar curves and their initial percent correction was 63.3%. The mean percent correction of all curves was 46.9%.
A field survey was made to discover the cases with Ossification of posterior longitudinal ligament in the cervical spine and 37 cases were found among 1431 workers. Analysis was made to investigate the relation of 37 cases to age, Sex, as well as regional and Occupational environment. 4 cases (1.67%) were recognized in agrarian labourers, 3 cases (2.6%) in forestry labourers, 4 cases (3.92%) in fishermen, 14 cases (2.68%) in School techers and 12 cases (2.66%) in other occupetion.
Short term and long term follow-up post-operative results were investigated in patients with cervical myelopathy (Spondylotic, due to developmental canal stenosis and due to ossification of the posterior longitudinal ligament). Statistical evaluation was made to find the relation between each signs, each symptoms and general severity the patients had preoperatively, and the clinical postoperative results. There were 208 patients examined at 2 months after surgery and 80 patients examined at more than 3 years after surgery. In short term results no significant relation was found between preoperative general severity and postoperative results, but motor dysfunction of the lower extremities and sphincter disturbance had a close relation between the preoperative clinical factors and postoperative results. In long term follow-up, preopeative general severity had a close relation with the post-operative results. Motor dysfunction of the lower extremities was the only preoperative factor in symptoms and signs with a significant linear association between its presence and postoperative disabilities. Sphincter disturbance had no significant relation with post-operative resuin our investigations.
Seventy three patients with upper cervical spine injuries are reviewed. These 73 consisted of 2 atlanto-occipital dislocations, 8 fractures of atlas, 17 hangman's fractures, 33 fractures of dens, 6 fractures of axis-body and 10 atlantoaxial subluxations. Five cases of them had died when carried to our clinic. In acute stage most of them showed occipitalgia, nape pain, knock pain on C2 spinous process and limitation of neck movement. In some cases we could observe occipital neuralgia, hypelgesia or hypesthesia which were considered of upper cervical root symptomes. Twenty six of them showed cervical cord symptomes. In acute stage most of them were treated conservatively. Some cases of hangman's fractures, old fractures of dens and atlantoaxial subluxations needed operative procedures.
Of the twenty six patients with wide laminectomy for the lumbar canal stenosis in the past three years, we experienced five cases of post-operative lumbar canal stenosis. Among them, three cases were post-fusion stenosis and two cases were post-laminectomy stenosis. Except one, all cases have elapsed more than six years from the first operation. Operation findings Post-Fusion Stenosis: Instability of the disc just above fusion mass. Thickening and infolding of the ligamentum flavum. Hypertrophy and projection of the articular processes. Laminar hypertrophy. Post-Laminectomy Stenosis: Haevy scar tissue at the site of love's laminectomy. Ligamentous thickening and hypertrophy of the lamina.
1. Eighty-seven patients treated with lateral (intertransverse) fusion for several lumbar disease at Tamatsukuri Koseinenkin Hospital from 1968 through 1977 were followed up. 2. Total estimation of results is “nearly good” on Kono's Evaluation. 3. Most of operation were performed with using of Hasting's frame, midline incision and lateral approach to transverse process by splitting sacrospinalis muscle and without operating intervertebular joints.
Out of 790 outpatients with sciatica seen during 1973 and 1977, 156 cases underwent surgery at out clinic. 265 cases of the remaining 634 could be followed up over 1 year ith an average of 2 years and 7 months after the first examination: 1) Fifty-two cases (19.6%) had been treated surgically at other hospitals. 2) Signs and symptoms of the remaining non-operative 213 cases were remarkably improved in 107 cases (50.2%), improved in 79 cases (37.1%), unimproved 27 cases (12.9%).
The purpose of this study is to evaluate the results of reoperation of lumbar disc surgery. This report analyses that group of patients who required more than one surgical procedure. Twelve of 179 patients who initially underwent operation required two or more procedures. The reason for a second or third operation were 1) Recurrent disc lesion, same level as previous surgery: 6 2) Recurrent disc lesion, different level: 3 3) Segmental instability (pseudo arthrosis): 1 4) Adhesive archnoidites: 1 5) Spinal stenosis: 2
We have operated forty-six cases and fifty-three discs in recent three years and four months. Items of those operative procedures was Osteoplastic hemipartial laminectomy, thirty-one discs, Love's method, twenty-one discs, and Anterior Intervertebral body fusion, one. We reports as follows: preope symptoms and abnormal findings, operative procedures, myelogram's findings, operative findings and two cases.
Fifty six fractures of the lateral humeral condyle in children were treated from 1961 to 1976 in our clinic. Twenty five fractures were followed up on the average for five years. Fourteen boys and eleven girls were from one to ten years old. The internal fixations had been performed in twenty-one cases, and the plaster cast had been applicated in other three cases without dislocation. The deformities of elbow were found in follow-up study, and the varus deformity and the the decrease of normal valgus angle were recognized. The valgus deformity was seen in only one case except another case with pseudo-arthrosis. The roentogenogram showed that the overgrowth of the radial head were in thirteen cases, the epiphysis of lateral humeral condyle were irregular in eight cases, and the closures of the premature epiphysis were in six cases. It seems that the deformities of elbow are related to the reductions of fractures.
The end result of forty nine patella fracture which were treated surgically in the past four years was reviewed. Twenty four cases were treated by tension band method, nine were fixed by wiring without tension band and four were fixed by screws. Six total patellectomies and six partial patellectomies were performed. The result of treated by patellectomy was poor in almost all cases. No case of patellectomy has been required after tension band method which we utilize. From this result, we suggest that a favorable treatment of the patella fracture is to reduce fragments as possible and apply tension band. There was no difference in the result between tension band method and wiring or screw fixation. However plaster immobilization will be required after wiring or screw fixation.
In the past three years, we have experienced sixteen cases of fracture-dislocation of the ankle. 1) We've generally chosen open reduction and internal fixation to the severe fracture-dislocation of the ankle. 2) About fractures of the posterior malleolus of the tibia, we have recommended the internal fixation if the displacememt of the tibial articular surface is over the one third. 3) Principally the diastases of the distal tibio-fibular ligament have been treated by the tibio-fibular fixation using the bolt and we think the removal of the bolt had better been done as soon as the tibio-fibular ligament is healed. 4) The rupture of the deltoid ligament primary should be operated upon and sutured.
During a year from June 1977 to May 1978, 14 limbs in 14 patients with non-union were sent to our hospital. They were 8 males and 6 females who were from 17 years to 60 years of age, average 36.4 years. We examined the causes of the non-union roentgenographically. The results are following. 1. inadequate screw fixation, too short or erroneous location (7 cases) 2. small intramedullary Kirschner wire or Küntscher nail (3 cases) 3. too short plating (1 case) 4. incorrect indication of intramedullary nailing (1 case) 5. inadequate external fixation (1 case) 6. others (1 case) We treated them surgically by using of internal fixation and bone grafting. Successful results in 13 cases of 14 cases were obtained.
Five patients with fracture of femoral neck following pelvic irradiation have been seen in this hospital. The clinical and radiological appearances are described and the prognosis and treatment of this type of fracture are discussed. It is concluded that early finding and early conservative treatment of this type of fracture is most satisfactory.
Recently we experienced a case of nickel allergy. Case: A man of 38 years of age sustained open fracture of the right tibia and fibula on December 31, 1977. Osteomuscular decortication of the tibia, bone grafting and osteosynthesis with a metal plate were performed on March 15, 1978 for treatment of pseudoarthrosis. Four monthes later, redness, swelling and local fever were found on the lower leg. In patch tests and intradermal skin tests of the nickel were positive. After removal of metals, complete recovery was obtained.
One hundred and twenty cases of CDH were investigated roentgenographically. Eighty cases were treated by Lorenz's procedure and fourty cases by Pavlikbandage. The shaft-epiphysis angle and the acetabular angle were measured periodically. The shapes of the femoral heads were divided into three types at the age of three years. In most cases treated by Pavlik-bandage, the shapes of the femoral heads were circular and the average of shaft-epiphysis angle was 75° at the age of five years. Twenty-eight cases with caxa plana and valga of those treated by Lorenz's procedure showed increase of shaft-epiphysis angle and acetabular dysplasia.
9 congenital dislocated hips of 5 patients were reduced surgically. Using the combined procedure of open reduction and femoral varus osteotomy simaltaneously, the dislocated hip could be reduced concentrically and stably. None of the hip was re-dislocated after this operation. Range of motion of the operated hips did not decrease after the open reduction. By the open reduction the flexion contracture of the hip could be corrected and ambulatory ability was improved.
So many factors are suspected as causes of difficult to treat the congenital dislocation of the hip. 3 cases of recurrent congenital dislocation of the hip with persistent joint laxity were treated with variable method. However, it was so difficult to get a perfect reduction. We suspect that joint laxity is one of the causes of unsatisfactory reduction of congenital dislocation of the hip.
Usual method of shelf operation and acetabuloplasty, which have been used, cannot correct the defect in the anterior portion of the acetabulum. To correct this defect the author modified the Lance's acetabuloplasty and have used it for the past five years. The hip is exposed through the Smith-Petersen approach. A thin osteotome is inserted just proximal to the capsule almost parallel with the acetabularroof as far as the Y—cartilage from lateral to anterior part under control of fluoroscopy. With the osteotome the acetabular roof is prized down antero-laterally and inferiorly and hold it by a wedge of bone from iliac bone or from the femur when varus osteomy is carried out in the same operation.
Curtiss and Kincaid reported three cases of transient osteoporosis of the hip in pregnancy in 1959. Since then, 6 additional cases have been reported. The mechanism of demineralization remains uncertain. A 38-year-old woman was admitted to our hospital with pain of right hip joint. She was in pregnancy and she complained joint pain from 18 weeks in pregnacy. The patient had joint pain, limited hip motion and radiographic changes showing marked demineralization of the involved femoral head with preservation of the joint space. Laboratory data were normal with the exception of elevated sedimentation rates (ESR) which are compatible with third trimester of pregnancy. There was no history of trauma or infection. The clinical course of this patient was benign with full recovvery in about 6 months by conservative therapy. Mechanical compression of the obturator nerve with selective demineralization of the hip has been suggested as a cause of this syndrome. Obstruction of venous return during pregnancy has also been suggested as the etiology of this syndrome. However in our case no data are available to support these explanations.
We conducted a pathological examination on lesions, changes in the synovial membrane and vascular lesions in the necrotic region in 6 cases of renal transplantation (of them, 2 cases being bilateral) and 2 cases of SLE for a total of 8 cases, 10 femoral head which developed steroid induced necrosis of femoral head. There have been many reports on the pathological findings of steroid induced necrosis. In comparison of the “idiopathic” lesion and steroidal one, opinions are split into two, namely, one that says there is a difference and the other that says there is not. Our pathological examination, though unable to point out any abnormality, apparently suggested some difference between the two.